What medications should be prescribed for a patient with a left ventricular ejection fraction of 55%–59%?

No Specific Medications Required for EF 55-59%

For a patient with an ejection fraction of 55-59% without heart failure symptoms or other compelling indications, no specific heart failure medications are mandated based on ejection fraction alone. This EF range is considered normal to mildly reduced and does not meet criteria for heart failure with reduced ejection fraction (HFrEF) treatment protocols.

Clinical Context Determines Treatment

The key question is: Does this patient have heart failure symptoms? An EF of 55-59% falls into what guidelines now term "heart failure with nonreduced ejection fraction" (HFnrEF) only if the patient has actual signs and symptoms of heart failure 1.

If the Patient Has Heart Failure Symptoms (dyspnea, fatigue, edema):

Even with EF 55-59%, if symptomatic heart failure is present, consider the following evidence-based therapies:

First-Line Therapies:

• SGLT2 inhibitors (empagliflozin or dapagliflozin) - Class I recommendation across the entire LVEF spectrum for symptomatic HF 1, 2, 3
• Diuretics - For congestion management if fluid overload present 4

Additional Considerations:

• Mineralocorticoid receptor antagonists (MRAs) - Reasonable in symptomatic patients, particularly with EF closer to the lower end of this range 1, 2
• ARNi (sacubitril/valsartan) - May be considered, with greater benefit when LVEF is closer to 50% 2

If No Heart Failure Symptoms Are Present:

Focus on treating underlying conditions and risk factors rather than EF-directed therapy:

Hypertension Management:

• ACE inhibitors or ARBs if hypertension, diabetes, or chronic kidney disease present 5, 6
• Beta-blockers if post-MI, coronary artery disease, or rate control needed 5, 6
• Calcium channel blockers as alternative or add-on therapy 7

Post-Myocardial Infarction:

• Beta-blocker for 3 years minimum 5, 6
• ACE inhibitor indefinitely 5
• Consider continuing beta-blocker beyond 3 years 5

Coronary Artery Disease:

• Beta-blockers for symptom control 6
• ACE inhibitors 6
• Statins 5, 8
• Antiplatelet therapy 5

Critical Pitfalls to Avoid

Do not automatically prescribe HFrEF medications (the "four pillars" of ACE-I/ARB/ARNI, beta-blockers, MRAs, SGLT2i) based solely on an EF of 55-59%. These are indicated for EF ≤40% or symptomatic heart failure 4, 2.

Do not overlook the clinical picture. An EF of 55-59% with symptoms requires investigation for:

• Diastolic dysfunction
• Valvular disease
• Atrial fibrillation
• Other causes of symptoms

Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) if any degree of heart failure is present, as they worsen outcomes 4.

Practical Algorithm

1. Assess for heart failure symptoms (dyspnea, fatigue, edema, exercise intolerance)

   • If YES: Initiate SGLT2 inhibitor + diuretics as needed + consider MRA
   • If NO: Proceed to step 2

2. Identify comorbidities:

   • Post-MI or CAD: Beta-blocker + ACE inhibitor + statin + antiplatelet
   • Hypertension: ACE inhibitor/ARB (especially if diabetes or CKD) + consider beta-blocker or CCB
   • Diabetes: SGLT2 inhibitor may provide cardiovascular benefit even without HF
   • Atrial fibrillation: Beta-blocker for rate control

3. Optimize cardiovascular risk factors:

   • Blood pressure control
   • Lipid management with statins
   • Smoking cessation
   • Weight management
   • Exercise rehabilitation 8, 6

The evidence consistently shows that treatment should be symptom-driven and comorbidity-specific rather than EF-driven when LVEF is >50% 9, 10, 11. The recent shift toward treating "heart failure regardless of ejection fraction" applies primarily to symptomatic patients and those with documented heart failure syndrome, not to asymptomatic individuals with normal or near-normal EF 1, 11.